Excellent Care for All

Quality Improvement Plans (QIP): Progress Report for 2017/18 QIP

The Progress Report is a tool that will help organizations make linkages between change ideas and improvement, and gain insight into how their change ideas might be refined in the future. The new Progress Report is mostly automated, so very little data entry is required, freeing up time for reflection and quality improvement activities.

Health Quality Ontario (HQO) will use the updated Progress Reports to share effective change initiatives, spread successful change ideas, and inform robust curriculum for future educational sessions.

ID / Measure/Indicator from 2017/18 / Org Id / Current Performance as stated on QIP2017/18 / Target as stated on QIP 2017/18 / Current Performance 2018 / Comments
1 / Percentage of residents responding positively to: "What number would you use to rate how well the staff listen to you?"
( %; LTC home residents; April 2016 - March 2017; In house data, NHCAHPS survey) / 54641 / 78.00 / 90.00 / 93.00
Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help build capacity across the province.
Change Ideas from Last Years QIP (QIP 2017/18) / Was this change idea implemented as intended? (Y/N button) / Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others?
Implement new policy and education on advance care planning. / Yes / Our Social Worker takes the lead on meeting with Residents and their POA to discuss advance care planning and document their thoughts, values and wishes around end of life. This is not used as a directive but rather a guideline to visit over time to ensure that our care planning and discussion aligns with the residents wishes. We evaluate our advance care plan conversations and have received feedback that this discussion has been very valued by residents and families.
Include question in the resident satisfaction survey to determine what specific areas we can improve in order to improve in this area. / Yes / Annual satisfaction survey results are shared with Resident and Family Council as well as the care teams. We seek input and ideas from the teams on how we can improve.
To continue to implement strategies to increase participation at resident council meetings. / Yes / In 2017 in support of the Ontario Resident Council Association's new initiatives in promoting resident rights, Wellington Terrace now offers a presentation at meetings on describing how we are committed to the day to day examples of ensuring resident rights are acknowledged and then communicated throughout the team. The feedback from the residents on this effort has been appreciated as it helped to initiate increased dialogue at their meetings. Any effort to contribute to the content of the meeting is helpful as leadership within the resident group is limited at this time due to resident frailty and cognitive impairment.
Promote customer service and validation techniques with the interdisciplinary team. / Yes / Our BSO team has been instrumental in coaching and mentoring the interdisciplinary team on proattention plans for residents. In addition, our purposeful rounds initiative has ensured that the team is addressing the residents immediate needs in a proactive way.
ID / Measure/Indicator from 2017/18 / Org Id / Current Performance as stated on QIP2017/18 / Target as stated on QIP 2017/18 / Current Performance 2018 / Comments
2 / Percentage of residents who fell during the 30 days preceding their resident assessment.
( %; LTC home residents; 2017; CIHI portal) / 54641 / 19.03 / 17.00 / 23.35 / We will continue to implement quality improvement plans for this indicator in the 2018/2019 plan. It is important to note that when this number is adjusted taking into account risk, resident demographics and other variables, the rate is 18.4% compared with the provincial average of 16.2%
Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help build capacity across the province.
Change Ideas from Last Years QIP (QIP 2017/18) / Was this change idea implemented as intended? (Y/N button) / Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others?
Implement bed height policy and procedure and have all staff educated on the policy. / Yes / A dot is placed on the wall to identify for staff the height that the bed should be at to safely allow residents to get in and out of bed. All staff have been educated on this initiative
Collaborate with the continence team to create individualized toileting plans for residents. / Yes / This is an ongoing initiative.
Fix bed pendants to the foot of the bed so that they are not accessible for residents with a significant cognitive impairment. / Yes / This initiative ensures that only residents capable of safely operating bed controls have access to the pendants in order to reduce the hazard of compromised bed positions.
ID / Measure/Indicator from 2017/18 / Org Id / Current Performance as stated on QIP2017/18 / Target as stated on QIP 2017/18 / Current Performance 2018 / Comments
3 / Percentage of residents who were given antipsychotic medication without psychosis in the 7 days preceding their resident assessment
( %; LTC home residents; July - September 2016; CIHI CCRS) / 54641 / 19.38 / 19.00 / 15.68
Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help build capacity across the province.
Change Ideas from Last Years QIP (QIP 2017/18) / Was this change idea implemented as intended? (Y/N button) / Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others?
BSO education to staff at departmental meetings to determine what behaviours respond to antipsychotics and which behaviours do not. / Yes / The BSO nurse attended Registered Staff Meetings to educate on antipsychotic use. She also works with the neighborhood RPN to complete assessments in preparation for our geriatric psychiatrist clinic using this as an opportunity to educate on best practices.
Continue to enhance the bathing experience for residents through the environmental enhancements of the tub room as well as the inclusion of music in the bathing experience. / Yes / This initiative was completed in 2017 and now all 6 tub rooms have been decorated and have music for a more pleasurable bathing experience.
BSO outreach to families with a focus on customer service in order to build strong partnerships and create and individualized care plan to mitigate responsive behaviours. / Yes / Our Behaviour Support RPN participates in the admission process by talking with the residents family and developing a toolbox of interventions to help the resident to transition to the home. She then regularly updates families and keeps them informed on how there loved one is doing in terms of responsive behaviours.
Provide 2 GPA education sessions in 2017 / Yes / 99% of our entire interdisciplinary team is now trained in Gentle Persuasion Approach.